Impacts of Abstinence
Education on Teen Sexual
X ,. .,
n• I
£ r\
Activity, Risk of Pregnancy,
and Risk of Sexually
ChHstopher Trenholm
Barbara Devamy
Kenneth Fortson
Melissa dark
Lisa Quay BHdgespan
Transmitted Diseases
^ Z
Abstract
This paper examines the impacts of four abstinence-only education programs on
adolescent sexual activity and risks of pregnancy and sexually transm^itted diseases
(STDs). Based on an experimental design, the impact analysis uses survey data collected in 2005 and early 2006 from more than 2,000 teens who had been randomly
assigned to either a program group that was eligible to participate in one of the four
programs or a control group that was not. The findings show no significant impact
on teen sexual activity, no differences in rates of unprotected sex, and some impacts
on knowledge of STDs and perceived effectiveness of condoms and birth control
pills. © 2008 by the Association for Public Policy Analysis and Management.
INTRODUaiON
Over the past decade, abstinence education programs have gained increasing
support as an approach for reducing adolescent sexual activity and promoting
healthy behavior among teens. Authorized under the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, the Title V, Section 510 Abstinence
Education Program was one of the legislative centerpieces that increased both the
funding and visibility of abstinence education programs. Since fiscal year 1998,
the Title V, Section 510 Abstinence Education Program has allocated $50 million
annually for programs that teach abstinence from sexual activity outside of
marriage as the expected standard for school-age children. Under a matching block
grant program, states must match this federal funding at 75 percent, resulting in a
total of up to $87.5 million annually for Title V, Section 510 abstinence education
programs. All programs receiving abstinence education funding must comply with
the "A-H" definition of abstinence education outlined in Figure 1. This definition
requires programs to teach that abstinence is the only certain way to avoid
pregnancy and sexually transmitted diseases (STDs); A-H abstinence education
programs cannot provide instruction in or promote the use of contraception.
In 1998, Congress authorized a rigorous evaluation of Title V, Section 510 abstinence education programs. The resulting multiyear evaluation included a rigorous,
experimentally based impact evaluation designed to estimate the effects of abstinence education programs on teen sexual abstinence and related outcomes. Four
programs were included in the impact evaluation: (1) My Choice, My Future! in
Powhatan, Virginia; (2) ReCapturing the Vision in Miami, Florida; (3) Families
United to Prevent Teen Pregnancy (FUPTP) in Milwaukee, Wisconsin; and (4) Teens
in Control in Clarksdale, Mississippi.
Journal of Policy Analysis and Management, Vol. 27, No. 2, 255-276 (2008)
© 2008 by the Association for Public Policy Analysis and Management
.""p- ®W1LEY
Published by Wiley Periodicals, Inc. Published online in Wiley InterScience
V , ) i t
(www.interscience.wiley.com)
""^^
DOI: 10.1002/pam.20324
•y-i Impacts
of Absthieiice
Education
on Scxualh
Transitntfcd
Di.sease.s
A,
l i a v e a s n s e x c l i i s i \ c purp{ adolescents. Their e o n e e r n witb c o n i p r e h e n s i \ e sex
Jnnnuu'oj
l\i!isi have examinetl ciiecis on potential m e d i a t o r s ol beha\ior, sueh as attiUides lowarei ieen sex o r irilenlions to abstain, ralhei" ihan on behavi(jral o u t c o m e s
ibemseives. For- example, at a recent abstiiienee edtication evaltialion conterence,
severed studies reported signilicant etlecls |iics
tlit eclK relateii to
ahstiiieTice (ii S'i'D
risks. An adtiitioiia! health class
in ytli f!i"ade
cn\ 1,'red ahs( inence bni ditl not
i'o\i.'r SI I)s or
contracepi iw nse
Jimrmd
ManLlated sctiool
(.mi icnlLun lor 6th
thri>ui!h 8tli
mm()n to most abstinence education programs. F.ach progtam
conipiied with ihe "A-H" gtiidelincs, and iheii curricula shared a similat hnus and
had many specific topic areas in conmtoti. A common perception is ihat abstinence
educalion programs locus narrowly on teachirjg youth the single message olabslaining Ironi sexual acli\ity beloie mariiage. Restilts from ati irnplenienlanon atuil\sis
stiggesl lliis is not (he ease. F-or e.\aniple, in addition to a locus ot) abslinence. aiS
lotn- programs taughl youth abont ph\sical development and i'eproduction, promoled risk awareness, taught goal setling and giiod decisioti making, pro\it!ed
insttiiction about healthy relationships, and soiight (o help vouth de\elop inleipersoual and ri^k-avoiclance skills.
STUDY DESIGN AND METHODS
Somple Inroke
Sample intake took place near tiie begitming of three school \ears 1999 2000,
20(K) 2001, and 2OOU2OO2, In each of ihese veat-s, either progiatii or school staff
identified those vouth who uere eligible lo participate in the programs. Once ideniilied, eligible students were given a stuclv consent loi-m iha! noiilied parenls
ol iheir children's ehgibility for ihe program, e.Nplained the progratn anti the evaluation, and deseribed how selection lor the progratn would lake place through a lottery {t-andom assignment).
.Acn\e parental eonsenl was oblained lor eaeh student enrolled in the e\a!uaiionOnce consent was obtained. sttttieiUs were randomly assigned to either ihe program
or coiUt-ol group. In two of tfie lottr studs siies, the programs were noneieclixe
school-basetl programs, and \ i r l u a l l \ all sfndcEUs returned consent forms and uere
randomlv assignetl. The tesnits in the.se tuo siles- -My Choiee, M\ I'ttlttrei and
'feens in Control—therefore yenerali/e to all students of sinnlar age in ihose two
sehool districts. In the other t u o sites, the pt-ogiatiss were electiw, meainng ihat
eligible voulh could choose uhether to apply lor the program and, if ratulomlv
assigned to the program group, could also decide whether to participate. In lhe.se
two .siles, ihe results generalize lo all students who applied lor ihe abstinence
ediicahori progr^uii.
The lina! impact anal\sis sample includes 2,O,S7 youlh; just less ihan fiO petveiu
(1,209) were assigned to the prrigrani group, and the remainder-(848) were assigned
lo Uie control gt-oup ("(able 2). The sample sizes range from 414 voulh lor rUpi'P io
7 1 .S lor Teens in Control.
Data uete collected Irotn the studx sample ihrough a series of loui- snrvevs.
The^e included a baseline surves. admitiislered near the time that \ottlh began par(icipating in the study, and three foilow-ttp sur-\evs. The surAe\s uere administered
either in school tising a peti-and-paper instrumen! or b\ phone, and all intervie\veis wetv independetit data collectors no! associated with either the program or'
school district.
The impact lindings are based on data collected Irom the final lollou-up suiAe\,
which uas administered to studs \oiah betueen spring 2005 and uititer 2006. This
reliects a loi!ou-up period ol rough!v 42 !o 78 months alter youlh began pariicipaling
in the sltitly dependitig on the vear in uhich llie\ begati partieipatitig and ihe e^aet
timing ol the siitAey. The lespotise r-ale on this sui\ev ranged Irom 80 fo 84 percent
across the lour sitidy sites, leading lo an 82 percenl response rate (aerall.
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Journal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
Impacts of Abstinence Education on Sexually Transmitted Diseases I 265
number of sexual partners, expectations to abstain, and reported rates of pregnancy,
births, and STDs.
Knowledge ond Perceptions of Risks Associated with Teen Sexual Activity
Measures of knowledge include the ability of youth to identify STDs, their understanding of potential risks of unprotected sex, and their knowledge of potential
health consequences of STDs. Perceptions of risk include youth perceptions of the
effectiveness of condoms and birth control pills for pregnancy prevention and for
the prevention of several types of STDs, including human immunodeficiency virus
(HIV), chlamydia and gonorrhea, and herpes and human papillomavirus (HPV).
Analytic Methods
Although random assignment ensures that program and control group youth are
similar on average, regression models can improve statistical precision and control
for chance differences between the two groups. For each outcome measure, program impacts were estimated using weighted regression models that pooled data
from all f^our sites:
4
Yis = X
("'^ •S« + Ps Pis + Xisjs) + eis
(1)
where
Yis is an outcome variable for student i in site 5
Sis is an indicator equal to 1 if student i is in site 5; 0 otherwise
Pis is an indicator equal to 1 if student i is in the program group in site s; 0
otherwise
Xis is a vector of baseline characteristics for student i in site 5
as, j8s, and ys are site-specific coefficients to be estimated
Bis is a random error term
The estimate of coefficient j8s provides the site-specific impact estimate. Regressionadjusted mean outcomes for program group youth in a given site were computed as
the predicted value of the outcome variable for a student in that site who was in the
program group but otherwise had the average characteristics of the students in that
site; regression-adjusted means for control group youth were computed analogously.
The difference between the regression-adjusted means for program and control group
youth in a given site is equal to the impact estimate in that site.
The pooled impact estimate was obtained simply by averaging the estimated
impacts for each of the four individual sites. Specifically, the overall impact is the
average of the estimated impacts of each program:
4
IMPACT = ^ /3s/4
(2)
5=1
where /§s is the estimated impact in site 5 from equation (1). This approach was preferred to weighting each site according to the size of its sample. Because the relative sample sizes of the sites in the evaluation were not representative of any
broader populations, weighting each site according to the size of its sample would
have arbitrarily given some sites more importance when computing a pooled
Journal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
266 / Impacts of Abstinence Education on Sexually Transmitted Diseases
estimate. In contrast, the approach used here generates a more policy-relevant
parameter: the impact observed for an average site in the evaluation, recognizing
that each site represents a distinct approach to abstinence-only education. Although
this approach was preferred, results are similar for a pooled estimation model that
weights site-level impact estimates according to sample size.
The weights used in the regression models accounted for the vadabilify in the probabilify of selection to the program or control groups as well as for youth who did not
respond to the final follow-up survey. Selection weights were calculated as the inverse
probability of selection to the group of assignment. Nonresponse weights were calculated using standard modeling techniques to estimate the probability of survey nonresponse as a function of baseline covariates. Standard errors from the models were calculated taking into account the variability associated with these weights.
The regression models included a large number of variables (Xis) to control for
individual demographic and background characteristics measured from the baseline survey (Table 4). For the small fraction of the sample who did not complete a
baseline survey (fewer than 5 percent), a supplemental survey was administered at
the next survey to collect key demographic information such as age, gender, and
race/ethnicity. For other covariates, missing data on continuous measures were
imputed using the mean for the remainder of the sample in a given program site,
and missing data on categorical variables were either grouped with the omitted
(base) category if item nonresponse was low or split into a separate missing category if item nonresponse was nonnegligible.
In the two elective programs, a sizeable proportion of youth assigned to the program group did not participate in any program classes or other services, either
because they chose to participate in other activities or they confronted scheduling
conflicts or other participation barriers. (Nonparticipation among program group
youth was 35 percent in ReCapturing the Vision and 43 percent in FUPTP.) Nonparticipation reflects the reality of many abstinence (and other) programs that serve
youth on an elective basis, making it an important program feature to include in
this study. Nonparticipation does not bias study findings for these sites. It does,
however, reduce the statistical power of the study samples in these two sites, making it unlikely that a true program impact of modest size in either site (say, four or
five points on a proportional outcome) would be found statistically significant.
To account for nonparticipation among program group members, impact estimates were derived in two ways. The first was for the full program group, reflecting
the average impact of having the opportunity to participate in the program among
Table 4. Control variables used in the impact analysis.
Demographics
and Background
Characteristics
Site
Enrollment cohort
Date of interview
Responded to
previous surveys
Gender
Age
Race/ethnicity
Presence of mother figure
Presence of father figure
Parents married
Baseline
Contextual Factors
Communication with parents
Unmarried sister got
pregnant
Sibling dropped out of school
Religiosity
Expectations to have sex
Baseline Measures of
Behaviors and Potential
Mediators of Teen Sex
Had sex
Perceived consequences
of sex
Views on abstinence
Ability to resist
pressure for sex
Knowledge of STDs
Journal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
Impacts of Abstinence Education on Sexually Transmitted Diseases I 267
those who applied, whether or not the youth actually chose to participate. These
are the impact estimates presented in this paper. The second is only for those youth
in the program group who actually participated, derived by using the Bloom correction of dividing the full-sample impact estimate by the participation rate (Bloom,
1984). Because the standard errors and significance levels associated with the
participant-only estimates were roughly similar to those for the full program group,
impact estimates that were not statistically significant for the full program group were
not statistically significant for the participants either. As a result, the conclusions do
not differ substantively when based on one set of measures or the other.
RESULTS
Impacts on Abstinence and Sexual Behavior
None of the programs had statistically significant impacts on the rate of sexual
abstinence, whether measured as either always remaining abstinent or being abstinent during the last 12 months (Table 5). Overall, about half of youth in both the
control group and program group reported remaining sexually abstinent, and a
slightly higher proportion reported abstaining from sex during the 12 months prior
to the survey—55 percent of control group youth versus 56 percent of program
group youth. This small difference was not statistically significant. Across the four
sites, differences between the program and control groups were modest (5 percentage points or less) and not consistent in direction. On both measures, ReCapturing
the Vision displayed the largest positive difference between the groups, but neither
difference was statistically significant.
Program and control group youth also did not differ in the number of partners
with whom they had sex (Figure 2). About one-quarter of all youth in both groups
had sex with three or more partners and about one in six had sex with four or more
Table 5. Estimated impacts on abstinencefromsexual intercourse, overall and by site.
49
56
49
55
0
1
0.91
0.76
38
45
38
44
1
1
0.90
0.79
44
48
40
43
0.32
0.28
60
65
62
67
-3
—2
0.61
0.71
53
66
57
68
-4
-2
0.34
0.64
Ul
Four Programs Combined
Remained abstinent (always)
Abstinent last 12 months
My Choice, My Future!
Remained abstinent (always)
Abstinent last 12 months
ReCapturing the Vision
Remained abstinent (always)
Abstinent last 12 months
FUPTP
Remained abstinent (always)
Abstinent last 12 months
Teens in Control
Remained abstinent (always)
Abstinent last 12 months
Ul
Program-Control
Program Group Control Group
Difference
(Percentage)
(Percentage) (Percentage Points) p-value
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005), administered to youth 42 to 78 months after enrolling in the Title V, Section 5tO Abstinence Education Program study sample.
Note: All estimates are based on weighted regression models.
Joumal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
268 / Impacts of Abstinence Education on Sexually Transmitted Diseases
75% -
50% "
49% 49%
25% -
16% 16%
•
o%Remained
abstinent
One partner
11% 11%
, Two
1= partners
1
I Program
17% 16%
8%
8%
Three partners
'A .'
*>"
Four or more
partners
• Control
Figure 2. Estimated impacts on reported number of sexual partners.
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005), administered to youth 42 to 78 months after enrolling in the Title V, Section 510 Abstinence Education Program study sample.
Note: All estimates are based on weighted regression models.
partners. Distributions for each of the four sites (not shown) likewise show no
statistically significant differences between the program and control groups.
Programs did not affect the age at which sexually active youth first engaged in
sexual intercourse (data not shown). Based on a question asking sexually active
youth the age at which they first had sex, the reported mean age at first intercourse
is identical between the program and control groups, 14.9 years. This estimate is
nonexperimental because age at first sex was only estimated among youth who had
had sex; however, results for the fiill sample examining the proportion who had sex
by a particular age are consistent with the programs having had no impact on age
of first sex.
Program group youth were no more likely than control group youth to have
unprotected sex. Seven percent of all program group youth and 8 percent of all control group youth reported having had sexual intercourse and not using condoms the
first time (Table 6). There are similarly no differences when measured over the last
12 months—17 percent of both program and control group youth reported having
had sex in the last 12 months and using a condom only sometimes, and 4 percent
in both groups reported having had sex in the last 12 months and never using condoms. For all youth, this latter result implies that 47 percent of youth who were
sexually active in the past 12 months had unprotected sex. Across the individual
programs, estimated impacts on unprotected sex, measured either at first intercourse or in the last 12 months, were likewise small and statistically insignificant.
Ten percent of youth in both the program and control groups reported having been
pregnant or gotten someone pregnant; roughly half of them (5 percent overall)
reported that they had had a baby, and there were no statistically significant differences between the program and control groups on these measures (Table 6). With
respect to STDs, only a small fraction of youth in both groups, about 5 percent overall, reported being told by a doctor that they had an STD. (Of course, many youth
may be unaware they have an STD.) Across the individual program sites, impacts on
these outcomes were not statistically significant.
Journal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
Impacts of Abstinence Education on Sexually Transmitted Diseases I 269
Table 6. Impacts on unprotected sex and consequences of teen sex, all four programs
rnmhinpri
Program
Control
Program-Control
Group
Group
Difference
(Percentage) (Percentage) (Percentage Points) p-value
Unprotected Sex at First Intercourse
Remained abstinent (always)
49
Had sex, used condom first time
44
Had sex, no condom first time
7
F-test of distributional differences
Unprotected Sex in the Last 12 Months
Abstinent last 12 montbs
56
Had sex, always used condoms
23
Had sex, sometimes used condoms
17
Had sex, never used condoms
4
F-test of distributional differences
Consequences of Teen Sex
Ever been pregnant
10
Ever had a baby
5
Ever had an STD (reported)
5
49
43
8
0
1
—1
0.91
0.59
0.45
0.40
55
23
17
4
1
—1
0
0
0.76
0.77
0.88
0.84
0.95
10
5
4
1
-1
1
0.68
0.56
0.53
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005),
administered to youth 42 to 78 months after enrolling in the Title V, Section 510 Abstinence Education
Program study sample.
Note: All estimates are based on weighted regression models. Program-control difference may not
equal difference in percentages due to rounding. F-tests of distributional differences are computed
from multinomial logistic regressions of the categorical outcome variable on an indicator for program
status and the baseline control variables.
Impacts on Knowledge of STDs ond Risks Associated with Teen Sex
On the final follow-up survey, youth were given a list of 13 diseases and asked
whether or not each was a sexually transmitted disease; of these diseases, nine were
actual STDs and four were not STDs. Youth in the program group identified an
average of 69 percent of these diseases correctly, as STDs or not, whereas youth in
the control group identified an average of 67 percent correctly. Although small, this
difference is statistically significant (Table 7). Comparing the four programs on
this measure, the impact estimate for My Choice, My Future! drives the pooled result.
It raised the rate of STD identification by an estimated eight points, from a mean of
75 percent for the control group to a mean of 83 percent for the program group.
Findings remain consistent when examining impacts separately for diseases that
are STDs and those that are not. Overall, program group youth correctly identified
a higher percentage of diseases of both types, though only the impact on true STDs
remained statistically significant (Table 7). This consistency suggests that programs
did not simply raise the likelihood that youth believed any disease was transmitted
sexually; rather, they had a beneficial long-term impact on STD identification.
Many study youth understood the risks of pregnancy and STDs from unprotected
sex, but they often lacked an understanding of the potential health risks from STDs.
On a two-item scale measuring their understanding of unprotected sex risks, youth
in both the program and control groups had high scores (0.88) (Table 7). On a threeitem scale measuring their understanding of potential health risks of STDs, however.
Journal of Policy Analysis and Management DOI; 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
270 / Impacts of Abstinence Education on Sexually Transmitted Diseases
Table 7. Estimated impacts on STD identification, knowledge of pregnancy and STD risks,
overall and by site.
Program
Control
Group
Group
Program-Control
(Scale Mean) (Scale Mean)
Difference
p-value
Four Programs Combined
Overall identification of STDs
Identification of true STDs
Identification of false STDs
JCnowledge of unprotected sex risks
Knowledge of STD consequences
69
75
57
0.88
0.52
67
72
55
0.88
0.51
2
2
2
0.00
0.02
0.00***
0.01***
0.10
0.85
0.20
My Choice, My Future!
Overall identification of STDs
Identification of true STDs
Identification of false STDs
Knowledge of unprotected sex risks
Knowledge of STD consequences
83
85
78
0.98
0.60
75
77
70
0.94
0.55
8
8
8
0.03
0.05
000***
000***
0.00**
0.04**
0.05*
ReCapturing the Vision
Overall identification of STDs
Identification of true STDs
Identification of false STDs
Knowledge of unprotected sex risks
ICnowledge of STD consequences
74
79
64
0.92
0.56
72
76
63
0.95
0.56
2
3
1
-0.03
0.00
0.16
0.11
0.70
0.09*
0.90
FUPTP
Overall identification of STDs
Identification of true STDs
Identification of false STDs
Knowledge of unprotected sex risks
Knowledge of STD consequences
63
70
48
0.88
0.52
65
70
52
0.86
0.47
-1
0
-4
0.02
0.05
0.45
0.90
0.22
0.47
0.08*
Teens in Control
Overall identification of STDs
Identification of true STDs
Identification of false STDs
Knowledge of unprotected sex risks
Knowledge of STD consequences
57
64
39
0.74
0.40
56
65
36
0.75
0.44
1
0
4
-0.01
-0.04
0.55
0.85
0.11
0.64
0.07*
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005),
administered to youth 42 to 78 months after enrolling in the Title V, Section 510 Abstinence Education
Program study sample.
Note: All estimates are based on weighted regression models. Program-control difference may not
equal difference in means due to rounding.
***p-value (of program-control difference) < 0.01; **p-value < 0.05; *p-value < 0.10, two-tailed test.
the mean values on this scale were relatively low (0.52 and 0.51 for prograrn and
control youth, respectively) and corresponded to a typical youth answering only
about half the items of the scale correctly. Overall, there were no statistically significant impacts on these scales.
Despite the overall lack of impacts on these scales, one of the programs. My Choice,
My Future! shows consistent evidence of improving youth knowledge of the risks of
unprotected sex and STDs. On both scales shown in Table 7, the mean among program group youth in My Choice, My Future! was significantly higher than among
their control group counterparts, reflecting a gain in knowledge attributable to the
Journal of Policy Analysis and Management DOI: 10.1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
Impacts of Abstinence Education on Sexually Transmitted Diseases I 271
program. Other programs also displayed some statistically significant differences
between program and control group youth on the two scales, but these differences are
less consistent.
Impacts on Perceptions of Pregnoncy and STD Prevention
Perceived Effectiveness of Condoms
Program and control group youth had similar perceptions about the effectiveness
of condoms for pregnancy prevention (Table 8). About half of the youth in both
groups reported that condoms usually prevent pregnancy, and 38 percent reported
that condoms sometimes prevent pregnancy. Only 3 percent of youth reported that
condoms never prevent pregnancy, whereas 7 percent reported being unsure.
With respect to STD prevention, a substantial proportion of youth in both the
program and control groups reported being unsure about the effectiveness of
condoms at preventing STDs. For example, roughly one-quarter of youth in both
groups reported being unsure about whether condoms are effective at preventing
chlamydia and gonorrhea or at preventing herpes and HPV. In addition, a sizeable
fraction in both groups, about one in seven, reported being unsure about condoms'
Table 8. Estimated impacts on perceived effectiveness of condoms for preventing
pregnancy and STDs.
Control Group
(Percentage)
Program-Control
Difference
(Percentage Points)
Condoms Prevent Pregnancy
Usually
51
Sometimes
38
Never
3
Unsure
7
52
38
3
7
-1
0
1
0
0.63
0.88
0.49
0.83
Condoms Prevent HFV
Usually
34
Sometimes
30
Never
21
Unsure
14
38
30
17
15
-4
0
5
-1
0.07*
0.97
0.01**
0.76
Condoms Prevent Chlamydia and Gonorrhea
Usually
30
35
Sometimes
27
25
Never
20
14
Unsure
23
26
-5
2
6
-3
0.03**
0.37
0.00***
0.15
Condoms Prevent Herpes and HPV
Usually
26
Sometimes
26
Never
23
Unsure
25
-5
1
7
-3
0.03**
0.77
0.00***
0.10*
Program Group
(Percentage)
31
26
15
28
p-value
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005),
administered to youth 42 to 78 months after enrolling in the Title V, Section 510 Abstinence Education
Program study sample.
Notes: Program-control difference may not equal difference in percentages due to rounding.
***p-value (of program-control difference) < 0.01; **p-value < 0.05; *p-value < 0.10, two-tailed test.
Joumal of Policy Analysis and Management DOI: 10.1002/pam
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272 / Impacts of Abstinence Education on Sexually Transmitted Diseases
effectiveness for preventing HIV. These findings contrast with those for pregnancy
prevention, for which very few youth in either group reported being unsure about
condoms' effectiveness.
Program group youth were less likely than control group youth to report that
condoms are usually effective at preventing STDs, and they were more likely to
report that condoms are never effective at preventing STDs. For example, 21 percent
of program group youth reported that condoms never prevent HIV, compared to
17 percent of control group youth. For herpes and HPV, 23 percent of program group
youth reported that condoms are never effective, compared to 15 percent of control
group youth.
The differences in the perceived effectiveness of condoms in preventing STDs are
largely the result of one program—My Choice, My Future! As discussed earlier, in
this program site, program and control group youth differed significantly in the
health and sex education services received by youth. Moreover, this abstinence education program had a strong emphasis on STD knowledge; the tenth-grade program
featured slide-show materials from the Medical Institute of Sexual Health, which
provided detailed information on STDs and instructed students that abstinence is
the only certain way to avoid contracting them.
Perceived Effectiveness of Dirth Control Piils
Just over 55 percent of the youth in both the program and control groups reported
that, when used properly, birth control pills usually prevent pregnancy (Table 9).
With respect to STD prevention, more than two out of three youth reported, correctly, that birth control pills do not prevent STDs. And for each type of STD investigated, a significantly higher proportion of youth in the program group than in the
control group reported this was the case. For example, 73 percent of program group
youth correctly reported that birth control pills never prevent HIV compared to
69 percent of control group youth, a statistically significant difference of four points.
DISCUSSION
The evaluation of abstinence education programs has been conducted over a period
of nine years. It started just after the funding authorization in 1998 and focused on
the "first generation" of the A-H abstinence education programs. The evaluation has
included both implementation and impact analyses, with multiple site visits to
observe the programs and longitudinal follow-up of study youth over a period of
four to six years. Several prior DHHS study reports document the implementation
experiences of the schools and communities operating the programs and first-year
impacts of the programs on potential mediating outcomes (Devaney, Johnson,
Maynard, & Trenholm, 2002; Maynard et al., 2005). These studies, together with
this final impact analysis study, highlight several important considerations for
addressing persistent concerns associated with teen sexual activity.
The abstinence education models tested in these four programs did not reduce teen
sexual activity. Findings from this study contribute to the policy debate on whether
abstinence education is effective at reducing teen sexual activity and its negative
consequences, as well as whether abstinence education puts teens at increased risk
of pregnancy and STDs. The impact results from four selected programs show no
impacts on rates of sexual abstinence. About half of all study youth had remained
abstinent at the time of the final follow-up survey, and program and control group
youth had similar rates of sexual abstinence. Moreover, the average age at first sexual intercourse and the number of sexual partners were almost identical for program and control youth.
Journal of Policy Analysis and Management DOI: 10.1002/pam
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Impacts of Abstinence Education on Sexually Transmitted Diseases I 273
Table 9. Estimated impacts on perceived effectiveness of birth control pills for preventing
pregnancy and STDS.
Program Group
(Percentage)
Control Group
(Percentage)
Program-Control
Difference
(Percentage Points)
p-value
Birth Control Pills Prevent Pregnancy
Usually
56
33
Sometimes
3
Never
7
Unsure
55
36
3
7
1
_2
0
1
0.55
0.32
0.62
0.65
Birth Control Pills Prevent HIV
Usually
6
6
Sometimes
73
Never
16
Unsure
6
7
69
18
0
_2
4
-2
0.94
0.15
0.04**
0.15
Birth Control Pills Prevent Chlamydia
and Gonorrhea
4
Usually
6
Sometimes
71
Never
19
Unsure
5
5
67
23
-1
0
4
-3
0.15
0.71
0.03**
0.06*
Birth Control Pills Prevent Herpes
and HPV
4
Usually
4
Sometimes
71
Never
21
Unsure
5
6
67
22
-1
-2
3
-1
0.54
0.08*
0.09*
0.64
Source: Wave 4 Survey of Teen Activities and Attitudes (Mathematica Policy Research, 2005),
administered to youth 42 to 78 months after enrolhng in the Title V, Section 510 Abstinence Education
Program study sample.
Note: Program-control difference may not equal difference in percentages due to rounding.
***p-value (of program-control difference) < 0.01; **p-value < 0.05; *p-value < 0.10, two-tailed test.
Contrary to potential concerns raised by some policymakers, researchers, and
health educators, the selected abstinence education programs did not increase
the risks of teen pregnancy and STDs. Some have questioned the A-H abstinence
education programs, believing that the focus on abstinence may put teens at risk of
having unprotected sex. The evaluation findings suggest that this is not the case. Program and control group youth showed no difference in their rates of unprotected
sex, either at first intercourse or over the last 12 months. Over the last 12 months,
for example, 21 percent of both program and control group youth (47 percent of
sexually active youth) reported having had sex and not always using a condom.
Teens have important gaps in knowledge of STDs. Both program and control
group youth appear better informed about the risks of pregnancy than about the
risks or consequences of contracting STDs. On a scale measuring STD identification, youth were correct only about two-thirds of the time; and on a scale measuring their understanding of the health consequences of STDs, youth on average got
only about half of the answers correct. Moreover, although a high proportion of
youth reported that having unprotected sex just once could result in an STD, 47 percent of sexually active youth had unprotected sex in the previous 12 months.
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274 / Impacts of Abstinence Education on Sexually Transmitted Diseases
Many abstinence education programs focus on the risks of STDs, and the evaluation results show some improvements in knowledge of STDs. Program group youth
correctly identified a significantly higher proportion of STDs than control group
youth, and program group youth were significantly more likely than control
group youth to report (correctly) that birth control pills are never effective at preventing STDs (including HIV, chlamydia and gonorrhea, and herpes and human
papillomavirus [HPV]). For both outcomes. My Choice, My Future! is the main
source of the differences seen overall.
Program group youth, however, were less likely than control group youth to perceive condoms as effective at preventing STDs. Compared with control group youth,
program group youth were less likely to report that condoms are usually effective
at preventing HIV, chlamydia and gonorrhea, and herpes and HPV. Furthermore,
program group youth were more likely than control group youth to report that condoms are never effective at preventing these STDs. As above. My Choice, My Future!
is a main source of these overall impacts.
Targeting youth at young ages may not be sufficient or effective. As with the four
programs in this study, most abstinence education programs have been implemented
in upper elementary and middle schools. In addition, most programs are completed
before youth enter high school, when rates of sexual activity increase and many
teens are either contemplating or having sex. Findings from this study provide no
evidence that abstinence programs implemented in upper elementary and middle
schools are effective at reducing the rate of teen sexual activity several years later.
However, the findings provide no information on the effects programs might have
had if they were implemented for high school youth or began at earlier ages but
served youth through high school.
In addition, at the time when most abstinence education programs are completed and youth enter their adolescent years, support for abstinence among their
friends falls dramatically. For example, survey data from the start of the impact
study show that nearly all youth had friends who exhibited attitudes and behaviors
supportive of abstinence. Four years later, however, the typical youth in the study
reported that only two of his or her five closest friends remained supportive of
abstinence.
Looking Ahead
This study examined only four programs, which began serving study youth in
either upper elementary or middle schools within a few years after the start of
the Title V, Section 510 abstinence education funding in 1998. The programs
were selected because they held promise; they appeared well implemented and
replicable, had curricula consistent with the A-H program guidelines, and were
relatively intense. Nevertheless, the findings for these programs may not reflect
the experiences of abstinence programs more broadly, particularly those that
have been developed more recently or that serve older teens in high school
settings.
Overall, this evaluation highlights the challenges faced by programs aiming to
reduce adolescent sexual activity. Nationally, about half of all high school youth
report having had sex, and more than one in five students report having had four
or more sexual partners by the time they complete high school. One-quarter of
sexually active adolescents nationwide have an STD, and many STDs are lifelong
viral infections with no cure. Findings from this study speak to the continued need
for rigorous research on how to combat the high rate of teen sexual activity and its
negative consequences.
Journal of Policy Analysis and Management DOI: 10,1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
Impacts of Abstinence Education on Sexually Transmitted Diseases I 275
CHRISTOPHER TRENHOLM is Associate Director of Research at Mathematica
Policy Research.
BARBARA DEVANEY is Senior Vice President and Managing Director at Mathematica
Policy Research.
KENNETH FORTSON is a Researcher at Mathematica Policy Research.
MELISSA CLARK is a Senior Researcher at Mathematica Policy Research.
LISA QUAY BRIDGESPAN is an Associate Consultant for the Bridgespan Group in
San Francisco, CA.
JUSTIN WHEELER is Director of High School Placement at the KIPP Philadelphia
Charter School.
ACKNOWLEDGMENTS
We would like to thank Rebecca Maynard, former Project Director and Co-Principal Investigator, whose hard work, creative thinking, and unwavering commitment to rigorous evaluation
design made this study possible. We also thank the abstinence education grantees who agreed
to participate in this evaluation, two anonymous referees, and the following individuals who
provided valuable guidance, comments, and support throughout the study—Meredith Kelsey,
Amy Johnson, members of the Abstinence Technical Work Group, Martha Moorehouse,
Barbara Broman, Lisa Trivits, Nicole Gardner-Neblett, Peter Schochet, Alan Hershey, and
William Garrett. This study was funded by the Office of the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human Services, contract no, HHS 100-98-0010,
The opinions and conclusions expressed in this paper are those of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or others.
REFERENCES
Bamett, J. E., & Hurst, C, S, (2003), Abstinence education for rural youth: An evaluation of
the Life's Walk program. Journal of School Health, 73, 264-268,
Bloom, H. (1984), Accounting for no-shows in experimental design. Evaluation Review, 8,
225-246,
Borawski, E, Lovegreen, L,, Demko, C, Guwatudde, D,, Abbott, K., & Stewari;, S. (2001).
Evaluation of the teen pregnancy prevention programs funded through the wellness block
grant (1999-2000). Cleveland, OH: Center for Health Promotion and Research, Department of Epidemiology and Biostatistics, Case Western Reserve University,
Denny, G,, & Young, M, (2006). An evaluation of an abstinence-only sex education curriculum: An 18-month follow-up. Joumal of School Health, 76, 414-422.
Devaney, B., Johnson, A., Maynard, R. A., & Trenholm, C. (2002). The evaluation of abstinence education programs funded under Title V, Section 510: Interim report. Washington,
DC: U.S. Department of Health and Human Services.
DiEiore, K,, Mays, V., & Ross, S. (2007). The effects of an interactive, computer-based, abstinence education curriculum on selected student outcomes, Califomian Joumal of Health
Promotion, 5, 55-61,
Doniger, A, S., Riley, J. S., Utter, C. A,, & Adams, E. (2001), Impact evaluation of the "Not Me,
Not Now" abstinence-oriented, adolescent pregnancy prevention communications
program, Monroe County, NY, Joumal of Health Communication, 6, 45-60.
Joumal of Policy Analysis and Management DOI: 10,1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
276 / Impacts of Abstinence Education on Sexually Transmitted Diseases
Edwards, D,, Bellar, S., Scearce, L., & Cathell, A. (2007). Evaluation of WhykNOw Abstinence
core curriculum and Road to Excellence programs. Presentation at the 2007
Abstinence Education Evaluation Conference: Strengthening Programs Through Scientific
Evaluation, Baltimore, MD. Retrieved September 30, 2007, from http://www ent-s-t com/
ESTOPA/ slides.htm.
Halpin, G,, & Halpin, G, (2007), Abstinence education: Program evaluation with youth survey Presentation at the 2007 Abstinence Education Evaluation Conference: Strengthening
Programs Through Scientific Evaluation, Baltimore, MD. Retrieved September 30, 2007,
from http://www.ent-s-t.com/ESTOPA/slides.htm,
Kirby, D, (2002), Do abstinence-only education programs delay the initiation of sex among
young people and reduce teen pregnancy? Washington, DC: National Campaign to Prevent
Teen Pregnancy,
Lemer, R, (2004). Can abstinence work? An analysis ofthe Best Friends Program. Adolescent
and Family Health, 3, 185-192.
Mathematica Policy Research, (1999). Wave 1 survey of teen activities and attitudes. Princeton,
NJ: Author.
Mathematica Policy Research (2005). Wave 4 survey of teen activities and attitudes. Princeton,
NJ: Author,
Maynard, R, A,, Trenholm, C, Devaney B,, Johnson, A,, Clark, M. A,, Homrighausen, J., &
Kalay, E, (2005). First-year impacts of four Title V, Section 510 abstinence-education programs. Washington, DC: U.S. Department of Health and Human Services,
Pickert, S,, Theis, L,, Wetta-Hall, R,, & Crowe, R. E. (2007). Abstinence education works:
Evaluation of the Pure & Simple Lifestyle project. Presentation at the 2007 Abstinence Education Evaluation Conference: Strengthening Programs Through Scientific Evaluation,
Baltimore, MD, Retrieved September 30, 2007, from http://www,ent-s-t.com/ESTOPA/
slides.htm,
Sather, L,, & Zinn, K. (2002), Effects of abstinence-only education on adolescent attitudes
and values conceming premarital sexual intercourse. Family & Community Health, 25,
Scher, L. S., Maynard, R. A., & Stagner, M. (2006), Interventions intended to reduce pregnancyrelated outcomes among teens. Retrieved September 30, 2007, from http://www,campbell
coUaboration.org/doc-pdf/teenpregreview dec2006.pdf.
Seufert, R, L., Carrozza, M. A., Kubilius, K. A., & Huber, V. (2007). Abstinence education program evaluation: structural equation modeling and social theory. Presentation at the 2007
Abstinence Education Evaluation Conference: Strengthening Programs Through Scientific
Evaluation, Baltimore, MD, Retrieved September 30, 2007, from http://www.ent-s-t,com/
ESTOPA/slides,htm.
Weed, S, E. (2001), Title V education programs: Phase I interim evaluation report to Arkansas
Department of Health. Salt Lake City UT: Institute for Research and Evaluation.
Weed, S. E., Olsen, J. A., DeGaston, J,, & Prigmore, J. (1992). Predicting and changing teen
sexual activity rates: A comparison of three Title XX programs. Washington, DC: Office of
Adolescent Pregnancy Programs.
Young, M., & Denny, G. (2007), An evaluation of an abstinence-only sex education curriculum; an 18-month follow-up. Presentation at the 2007 Abstinence Education Evaluation
Conference: Strengthening Programs Through Scientific Evaluation, Baltimore, MD.
Retrieved September 30, 2007, from http://www,ent-s-t,com/ESTOPA/slides,htm.
Joumal of Policy Analysis and Management DOI: 10,1002/pam
Published on behalf of the Association for Public Policy Analysis and Management
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